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Medical Records Quiz

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1. The process of assembling, filing, maintaining, retrieving,transferring,protecting, retaining and destroying medical records is called what/




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2. Originally enacted in 1996, this act contains requirements for patient confidentially. What is that ACT




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3. What does CONDITIONING mean?




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4. What is a EHR (Electronic Health Record)?




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5. What is an Audit?




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6. What does Active Medical Record mean?




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7. The chart of a patient not seen at the specific medical office within the past 2 to 5 years. What type of record is this?




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8. the chart of a patient not expected to return to the practice, such as a patient who is deceased or has moved.




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9. OUTGUIDES




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10. Problem-Oriented Medical Record - The patients problems are numbered and listed on a form (problem list) placed in front of chart




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11. A format with the MOST RECENT documenation filed on top of the past documentation




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12. Source-Oriented-Medical Reocrd -




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13. SOAP - The most common methods of documentaion in the medical office is a SOAP = Subjective-Objective-Assessment-Plan




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14. Patients Medical Record




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15. A format for documenting each medical visit using subjective information, obejective information, an assessment, and a plan in that order





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